Clinical profile, complications, and factors associated with mortality among children with rheumatic mitral stenosis in a resource-limited setting: a retrospective cohort study

Abstract Background Rheumatic mitral stenosis (MS) is an important cause of morbidity and mortality among children in low-resource settings. In Tigray, Ethiopia, cardiac surgical and catheter-based interventions are unavailable, and the clinical profile and outcomes of pediatric MS are poorly characterized. We assessed the clinical characteristics, complications, and factors associated with mortality among children with rheumatic MS. Methods We conducted a retrospective cohort study at Ayder Comprehensive Specialized Hospital, a tertiary referral center. We used records of children younger than 18 years with echocardiographically confirmed rheumatic MS diagnosed between April 2019 and April 2024. Ninety-eight children were included. Data were abstracted using a structured tool and analyzed with SPSS version 27 and R version 4.6.1. Factors associated with documented mortality were examined using univariable and multivariable Firth penalized logistic regression (logistf package); p < 0.05 was considered significant. Complications were coded as present if documented at any time during follow-up, and MS severity was taken from the last available echocardiogram. Results Mean age at diagnosis was 13.7 ± 3.0 years (youngest, 5 years). On the last echocardiogram, 59 children (60.2%) had severe MS. Heart failure was documented in 84.7%, and 61 of 75 children with available peak tricuspid regurgitation velocity (TR Vmax) measurements (81.3%) had a high echocardiographic probability of pulmonary hypertension. Moderate-to-severe thinness and stunting were present in 75.5% and 52.0% of children, respectively. Sixteen children (16.3%) died. Atrial fibrillation (adjusted odds ratio [AOR] 8.35; 95% CI 1.64–45.78; p = 0.011) and peripheral edema (AOR 4.77; 95% CI 1.35–17.86; p = 0.016) were associated with higher adjusted odds of mortality. Infective endocarditis showed a positive but non-significant association (AOR 4.72; 95% CI 0.91–22.80; p = 0.064). Conclusions In this tertiary-referral cohort without access to valve intervention, rheumatic MS in children was often severe on the last echocardiogram and accompanied by a high burden of malnutrition, complications, and mortality. Atrial fibrillation and peripheral edema were associated with higher odds of documented mortality in an exploratory model based on 16 deaths. The timing of these findings relative to death was unknown, so causal or prognostic effects cannot be inferred. Early detection, nutritional support, and access to definitive intervention merit attention.